Social Phobia 

Updated: Nov 20, 2018
Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD 

Overview

Background

Social phobia, also called social anxiety disorder, is the third most common mental health disorder after depression and substance abuse, affecting as many as 10 million Americans. Social phobia is an anxiety disorder involving intense distress in response to public situations.[1, 2] Individuals with social phobia typically experience symptoms resembling panic during a social encounter. These situations may include speaking in public, using public restrooms, eating with other people, or engaging in social contact in general.

Persons with this disorder fear being humiliated or embarrassed in social and/or performance situations by their actions and may become intensely anxious, with an increased heart rate, diaphoresis, and other signs of autonomic arousal. These physical symptoms may cause additional anxiety, often leading to a conditioned fear response that reinforces their anxiety in public situations.[1]

The onset of social phobia may or may not be abrupt, often manifesting after a stressor or humiliating social experience in an individual with a childhood history of excessive shyness or social inhibition. Social phobia is considered a disorder if it is severe enough to adversely affect social or occupational functioning.[3] Individuals with true social phobia go to great lengths to avoid social situations, usually to their own detriment. The fear of embarrassment is egodystonic, thus persons with social phobia are distressed by their symptoms.[4]

Pathophysiology

The pathophysiology of social phobia is evolving as a result of research into brain connectivity and function and recent hypotheses regarding cognition.

A functional connectivity study of 174 subjects, 78 of whom had social anxiety disorder, examined whether emotion regulation can be a transdiagnostic measure. Results showed that effectual regulation in the context of negative stimuli consisted of engagement of the Prefrontal Cortex (PFC) along with reduced amygdala reactivity, and greater symptom severity correlated with less engagement of the Dorsal Anterior Cingulate Cortex (DACC) and less functional connectivity between the amygdala and ventrolateral prefrontal cortex.[5]

Cognitive theories helpful in the understanding of the etiology of social phobia include the "Clark and Wells cognitive model of social phobia," which hypothesizes that self-focused attention, negative observer-perspective images of oneself, and safety behaviors maintain anxiety in subjects with social phobia and that this anxiety associates with observer-perspective imagery and safety-seeking behavior in adolescence; however, even though adolescents with clinical social phobia may report frequent negative self-focused thoughts, this may not be a clear associated symptom. However, such negative cognitions focused on self do not associate to self-reported social anxiety.[6]

Theories have also arisen looking at the efficacy of pharmacologic agents used to treat social phobia. Thus, serotonergic functioning might be involved, as serotonergic reuptake inhibitors help alleviate symptoms. Similarly, some researchers believe in an adrenergic etiology because of the success of propranolol therapy. Neurocircuitry involving the amygdala, a structure involved in fear, may be involved, as studies have found an exaggerated reactivity of the amygdala to aversive social stimuli in social anxiety.[7, 8]

Implications for treatment include the importance of not advancing treatment too quickly and triggering severe anxiety and early cessation of treatment; to enhance the ability to tolerate low levels of anxiety, the presence of a caregivier who is able to model adaptive functioning is desirable as an initial approach.[9]

Very low weight (600–1250 g) premature babies may also be at higher risk for later development of social anxiety disorder, possibly owing to abnormalities in the uncinate fasciculus, the major white matter tract connecting the frontal cortex to the amygdala, and other limbic temporal regions.[10]

One multisite study looked at whether treatment response was associated with specific genetic loci. Although treatment response was not assoicated with specific genetic loci, FKBP5, GR polymorphisms, or pretreatment percentage DNA methylation, the change in FKBP5 DNA methylation was nominally associated with treatment response as persons who demonstrated the greatest reduction in severity decreased in percentage DNA methylation during treatment compared with persons with one or more FKBP5 risk alleles who had little or no decrease or an increase in percentage of DNA methylation and did not show robust treatment response.[11]

Epidemiology

Frequency

United States

In the United States, 9% of youth experience social phobia at some point in their lifetime—a slightly lower rate than the 12.1% rate observed among US adults in the National Comorbidity Survey (NCS)-Replication study. This social phobia was associated with marked levels of impairment and persistence. However, adolescents did not have significant associations, when compared with adults, between social phobia and mood or alcohol use disorders, after controlling for comorbid disorders; this suggests these relationships may be due, in part, to other psychopathology.

The US NCS-Adolescent Supplement is the first study of social phobia in adolescents with a large community-based sample and was done from 2001–2004.[12]  This study of 10,123 adolescents aged 13–18 years in the continental United States had a very good overall response rate of 83.3% of parents/parental surrogates, who responded to a self-administered questionnaire. Additional scales of excellent quality were used, such as the modified version of the World Health Organization Composite International Diagnostic Interview (CIDI) Version 3.0 and the Sheehan Disability Scale, to determine the impact of the disorder on the adolescents’ general functioning.

The study used the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) criteria for social phobia and found no sex differences in incidence; data were statistically very reliable (P = .001-.01) that 4.8% of all adolescents, representing more than half (55.8%) of all adolescents with social phobia, had fear of most social situations — generalized social phobia (7 or more of the 12 types of social fears)—as follows:

  • Meeting new people their own age

  • Talking to people in authority (eg, coaches, other adults they do not know very well)

  • Being with a group of people their own age (eg, at a party, in the lunchroom at school)

  • Going into a room that already has people in it

  • Talking with people they do not know very well

  • Going out with/dating someone they are interested in

  • Any other situation in which they could be the center of attention or something embarrassing might happen (eg, working/doing homework while someone watches; writing/eating/drinking while someone watches; speaking in class when a teacher asks a question/when a teacher calls on them; acting/performing/giving a talk in front of a group of people; taking an important test/examination or interviewing for a job, although they are well prepared)

A smaller percentage (3.8%) of all adolescents, representing 44.2% of all those adolescents with social phobia, had nongeneralized type of social phobia—fewer than 7 types of fears.

A very much smaller percentage of all adolescents (0.7%) had performance social phobia, representing only 0.8% of all adolescents with social phobia. This is perhaps due to the fact that public speaking and performance fears may only become clinically significant with the greater opportunity for avoidance that characterizes adulthood, as youth are required, because of school, to participate in such situations. Thus, they have more occasions for exposure resulting in performance anxiety, habituation, and lower prevalence rates than occur in adults, who are able to avoid such situations.

Disability from social phobia of the generalized type was moderate to severe and highly persistent; 87.03% of adolescents experienced at least 7 fears for 4 days of the previous calendar year, and there was a high comorbidity with social phobia. About one third to one fifth of adolescents with generalized social phobia had another disorder, most often anxiety due to agoraphobia (27%), followed by panic disorder (20.5%), separation anxiety disorder (18.1%), posttraumatic stress disorder (17.1%), and specific phobia (12.8%).

Lifetime incidence of comorbid oppositional defiant disorder occurred in a significant number of adolescents, more so in those with generalized social phobia (12.5% compared with adolescents who had the nongeneralized type of social phobia). That group had lower rates of comorbid disorders, and there was a statistically significant rate (P = .05) of significant comorbid drug-use disorders in 13% of those with generalized social phobia, as compared with only 7.2% of those with nongeneralized social phobia.

A unique pattern was found — an association between generalized social phobia with agoraphobia and panic disorder. Nongeneralized social phobia had an association with posttraumatic stress disorder and a unique negative association with alcohol use disorders. Although overall 18.6% of adolescents with social phobia presented with a lifetime mood disorder, adjusted odds ratios indicated that these associations were primarily due to other anxiety or behavior disorder.

International

The lifetime prevalence of social phobia is estimated at 7%–12%.[3] Some community samples of adolescents show an incidence of 1.6%.[1, 2]

Social phobia often goes undiagnosed in patients with other coexisting acute psychiatric conditions such as depression or suicidality but should not be overlooked, as it can contribute to a lack of symptom remission. In some situations, social phobia may be the root cause of depressive or suicidal symptoms.[4, 13]

Mortality/Morbidity

Social phobia is often comorbid with other anxiety disorders; in one study, 60% of children with social phobia had another disorder (generally an anxiety disorder); 10% had generalized anxiety disorder, attention deficit/hyperactivity disorder (ADHD), or specific phobia. In other studies, children with social phobia were found to have comorbid separation anxiety disorder (in younger children), as well as selective mutism. Social phobia often leads to extreme social isolation in children and can be accompanied by selective mutism and/or can be a precursor to depression.

Intermitten explosive disorder (IED) can co-occur with social phobia. Data from the National Comorbidity Survey Replication and Adolescent Supplement Study indicated lifetime presence of an anxiety disorder increased the rate of IED by almost 3-fold (7.8% in adolescents without anxiety compared with 22.9% in adolescents with anxiety).[14]

In adults with social phobia, academic and occupational functioning may be affected; often, people with social phobia have significant trouble forming relationships with others.[8]

Social phobia can also be comorbid with autistic spectrum disorder. Longstanding social phobia increases the lifetime risk of depression later in adulthood, potentially leading to an increased risk of substance abuse, including alcoholism. This thereby confers a higher risk for cardiovascular morbidity and mortality.[15, 3, 16, 17]

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension and has been found in many cultures, not exclusively in Japan but also found in Hong Kong, China, India, South Korea, Spain and the United States.[18]

Race

Social phobia occurs in many cultures. Persons of Asian descent in North America may not receive treatment as early in the course of the disorder as persons of European descent. In addition, persons of Asian descent have significant cultural differences involving emotional responses in social interactions compared with persons of other cultures.[19, 20]

Sex

In the general population, more females than males develop social phobia, with a female-to-male ratio of 1.5–2:1; however, in clinical samples, cases involving males are more prevalent. The reasons for this prevalence are unknown.[21]

Age

Social phobia typically manifests in middle childhood, at approximately age 10 years. Adolescents (aged 11–12 y) with social phobia may avoid age-appropriate social activities, such as attending parties and dating. Symptoms of social phobia in younger children include crying, temper tantrums, fidgeting, somatic complaints, and avoidance and withdrawal from social situations. Untreated childhood social phobia typically continues into adulthood.[1, 15]

Interpersonal Stressors/Trauma Exposure

A recent study suggests that interpersonal stressors, including the particularly detrimental stressors of peer victimization and familial emotional maltreatment, may predict the later development of social anxiety symptoms in adolescents who have more immediate depressogenic reactions after stress.[22]

Prognosis

Mild social phobia is associated with a good prognosis and may have a benign course. Severe avoidance behavior and substance abuse are often associated witha guarded prognosis.

Symptoms of social phobia in younger children include crying, temper tantrums, fidgeting, somatic complaints, and avoidance and withdrawal from social situations.[1] The median delay from onset to seeking treatment can be as long as 28 years.[13] Untreated childhood social phobia typically continues into adulthood and thus can potentially cause significant duration of impairment and interfere with normal development.[15]

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension and has been found in many cultures, not exclusively in Japan but also found in Hong Kong, China, India, South Korea, Spain, and the United States.[18]

Patient Education

Recent naturalistic research looked at functional MRI activity in anxious children and adolescents who requested that their caregiver accompany them in the scanner room compared with those without their caregiver present. Results indicate that activity in the hypothalamus, ventromedial, and ventrolateral prefrontal cortex were significantly reduced in anxious children and adolescents who requested that their caregiver accompany them in the scanner room compared to those without their caregiver present. Mean activity in these regions in anxious children and adolescents with their caregiver in the scanner room was comparable to that of healthy controls. This suggests links between social contact and neural mechanisms of emotional reactivity, and that the presence of caregivers may lessen the increase in anxiety associated with stressful stimuli.[9]

Approaches to prevention of social phobia in school children include universal emotional health interventions using computer programs such as FRIENDS or Coping Cat to decrease anxiety symptoms and to improve self-eseteem, which may be helpful as long as the interventions specifically target social phobia.[23, 24, 25, 26, 27, 28]

The folllowing organizations may prove beneficial to patients and their families:

Patient and family education are important for helping resolve symptoms and preventing relapses. Family support may be helpful in behavioral desensitization techniques and in decreasing the social isolation of the patient. Patients and families should be educated regarding the nature, prognosis, and treatment of the disorder.

 

Presentation

History

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for social phobia are as follows:[29]

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. In children, the anxiety must occur in peer settings and not just during interactions with adults.

  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.

  • The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.

  • The social situations almost always provoke fear or anxiety. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

  • The social situations are avoided or endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance cause clinically significant distress or impairment in social, occupationals, or other important areas of functioning.

  • The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.

  • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.

  • If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

A Hypothetical Case Presentation

The chief complaint of a 9-year-old boy is, "No one likes me or wants to play with me, and I hate it when the teacher asks me to read aloud." He has difficulties with functioning at school, his teacher reports that he rarely raises his hand to be called on, and his mother reports that he has frequent stomachaches, especially the night before he is supposed to take standardized tests. At home, he seems content to play his clarinet by himself, and he tells the clinician that he dreads concerts because he is expected to play in front of others.

Physical

A thorough Mental Status Examination should be included, with the following areas specifically assessed:

  • General appearance: The patient may be noticeably uncomfortable or anxious in the office. The patient may be hesitant or have difficulty speaking. However, in one-on-one situations, the patient may not demonstrate significant social anxiety. Individuals observed to be silent or mute should undergo screening for selective mutism with the selective mutism questionnaire or other appropriate checklists that gather information from the child and other sources of information (eg, from parents or teachers).[30]

  • Mood/affect: Because depression is commonly comorbid with social phobia, the patient may report depressed or anxious mood and may appear to have a depressed or anxious affect.

  • Speech: The patient may speak softly and with hesitancy.

  • Thought processes: Thought processes in individuals with social phobia are usually in the "normal" range. Their thought processes are usually appropriately goal-directed and syntonic without morbid preoccupation or impairment of reality.

  • Perception: Auditory or visual hallucinations are not elements of social phobia; however, schizophrenia or acute stress disorder may be comorbid with social phobia.[31]

  • Thought content: The patient may be preoccupied with what others are thinking about him or her. Delusions are not present, but preoccupation with the scrutiny of others may approach delusional levels. True fixed delusions are not consistent with social phobia and are more suggestive of schizophrenia.[31]

    • A 2015 study of adolescents found that individuals with social anxiety disorder (SAD) displayed more frequent and intense paranoid thoughts than a control group and that the level of paranoid thoughts was significantly predicted by the degree of social phobia, even after adjusting for sex and other anxiety disorders, although adjusting for depression slightly reduced the extent and significance of the prediction.[32]

  • Cognition: Cognition is normal.

  • Suicidal/homicidal ideation: This is not common with social phobia per se, but the social isolation associated with social phobia can lead to despair, depression, and suicidal ideation. Thus, it is important to screen for depression, especially in the presence of obsessive thinking accompanied by compulsive behaviors.[33, 34]

Causes

Very low weight (600–1250g) premature babies may be at higher risk for later development of social anxiety disorder, possibly owing to abnormalities in the uncinate fasciculus, the major white matter tract connecting the frontal cortex to the amygdala, and other limbic temporal regions.[10]

Genetic factors may contribute to social phobia. Pedigree analyses suggest that first-degree relatives of probands with social phobia are 3 times more likely to have social phobia than controls. However, specific genes have not been isolated. An inhibited temperament in childhood has been linked with the development of social phobia in adolescence. The brain dysfunction in social phobia may result from increased activation of neural circuitry to fearful faces, specifically in the amygdala.[33, 34]

Paternal social anxiety is a specific risk factor for the development of childhood social anxiety. When fathers exhibit social anxiety, this can be interpreted by their children as a strong negative signal about the external social world and cause them to rationally adjust their beliefs and feel stressed instead of secure. This can hinder children developing feelings of security regarding individuation and autonomy.[35]

A cross-cultural perspective is essential, as individuals of some cultures (Japanese, Korean) may have a persistent and excessive fear of offending others in social situations, called taijin kyofusho. Specifically, the individual fears that his or her body odor, eye-to-eye contact, or blushing could be offensive to others.[36]

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension.[18]

The importance of culturally sensitive measures in diagnosis of social phobia and social anxiety is critical, although social phobia and social anxiety has been found in many cultures, not exclusively in Japan but also in Hong Kong, China, India, South Korea, Spain, and the United States. One study found differences in sensitivity of detection of the disorder finding that the Social Interaction Anxiety Scale and Social Phobia Scale were not as sensitive in detecting the disorder in test subjects from Japan compared with those from Australia.[37]

Preliminary findings of one study show possible blood biomarkers that may reflect increased risk for Hikikomori—lower serum HDL-C in females and lower serum uric acid in males—which may reflect an underlying mechanism of oxidative stress and inflammation increasing risk of social phobia.[38]

Physical Examination

Because elevated cortisol levels may worsen symptoms of social phobia, the history and cursory observation of the patient's habitus should include ruling in or out conditions that cause elevated cortisol levels (intrinsic or extrinsic) via taking blood pressure, pulse, and observing for abnormal facies like "mood facies."[39]

Complications

Social phobia has a wide range of severity. It may be mild and associated with minimal distress or may be severe to the point of causing marked disability. Extreme avoidance behavior (i.e., avoiding contact with others and being unable to maintain employment) sometimes complicates this condition.

Substance abuse, particularly the abuse of alcohol, sedatives, or narcotics, can also make treatment more difficult because benzodiazepines may not be appropriate or may need to be used with extreme caution in patients with substance dependency.

School refusal is a common complication of social anxiety disorder. A classic article highlights the importance of using cognitive behavioral therapy techniques for youth who are on an inpatient psychiatric unit to prevent school refusal.[40]

 

DDx

Differential Diagnoses

 

Workup

Approach Considerations

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension thus a physical exam and medical testing is important especially for persons with other risk factors such as physical inactivity and obesity.[18]

Preliminary findings of one study show possible blood biomarkers that may reflect increased risk for Hikikomori—lower serum HDL-C in females and lower serum uric acid in males—which may reflect an underlying mechanism of oxidative stress and inflammation increasing risk of social phobia.[38]

Individuals who scored high on a measure of being concerned with halitosis (the Halitosis Consequences Inventory) appeared to be at a higher risk of social anxiety, underscoring the importance of screening if a person presents to a health care professional with complaints of halitosis.[41]

Laboratory Studies

Basic laboratory studies are prudent to detect contraindications to medication treatment, as well as to screen for comorbid conditions such as anemia, low ferritin levels (especially in the presence of a sleep disorder), and hypothyroidism. Such studies might include a serum CBC count with differential, an electrolyte evaluation, liver function tests, metabolic screening and thyroid function tests.

Preliminary findings of one study show possible blood biomarkers that may reflect increased risk for Hikikomori—lower serum HDL-C in females and lower serum uric acid in males—which may reflect an underlying mechanism of oxidative stress and inflammation increasing risk of social phobia, thus indicating the importance of screening testing, especially for individuals at higher risk of cardiovascular complications, such as persons with an inactive lifestyle and obesity.[38]

Imaging Studies

Neither single-photon emission computed tomography (SPECT) nor functional MRI (fMRI) is clinically helpful in the diagnosis or treatment response in individuals with social phobia. However, these techniques are useful for excluding structural brain disease (tumor or infection). These techniques are also being used investigationally in research protocols; it has been shown that social anxiety is a different disorder from generalized anxiety disorder in terms of symptomology and brain structure.[42]

Cognitive distortions and self-monitoring in social situations result in hyperawareness of internal cues and intense arousal to the perceived negative aspects of social interactions. Studies have shown that the fear associated with the hyperawareness may be decreased or not occur at all with lesions in the area of the amygdala.[43]

During adolescence, brain changes may increase risk for development of social anxiety disorder due to increased insular sensitivity to negative reward prediction error processing.[44]

Other Tests

In general, social phobia is not associated with mitral valve prolapse, so echocardiography is unnecessary unless clinically indicated because of other symptoms or history.[21]

 

Treatment

Approach Considerations

A combination of pharmacotherapy and psychotherapy is usually indicated for persons with social phobia.

A pilot study is underway to determine if a one-session treatment might be as effective as multisession CBT to treat social anxiety.[45]

Medical Care

Pharmacotherapy

Antidepressants including selective serotonin reuptake inhibitors (SSRIs; citalopram [Celexa], escitalopram [Lexapro], fluvoxamine [Luvox], paroxetine [Paxil], fluoxetine [Prozac], sertraline [Zoloft]) and venlafaxine (Effexor) are commonly prescribed to treat the symptoms of social phobia and generally result in remission of symptoms after 4 weeks of treatment. However, it is important to balance benefits and the potential for adverse effects when prescribing medications.[46, 47, 4, 48]

  • SSRIs: SSRIs are quickly becoming the standard first-line medication for social phobia. Paroxetine received US Food and Drug Administration (FDA) approval for this indication in 1999, the first SSRI to gain such approval. In 2003, sertraline received FDA approval for short- and long-term (20-wk) treatment of social phobia in adults. It is also FDA-approved for the treatment of obsessive-compulsive disorder (OCD) in children older than 12 years.

  • Serotonin norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine, were approved for the treatment of social phobia in 2003 for use in adults but may not be as effective or safe in children. Studies suggest that other SSRIs may also be effective. However, the FDA recommends caution when using these agents to treat social phobia in children younger than 18 years because of concerns about the potential increased risk of newly onset suicidal ideation, especially with venlafaxine and paroxetine. Nonetheless, numerous open and controlled studies support the efficacy of SSRIs/SNRIs in this population as part of a multimodal approach, with close monitoring of mental status.[49, 50, 47, 4]

  • Benzodiazepines: Benzodiazepines may be effective for social phobia but are generally undesirable in the absence of contraindications to SSRI use. Alprazolam and clonazepam have been used successfully for this indication, but all agents in this class, although very helpful in comorbid panic, should not be used for longer than 6 weeks because of the risk of increased depression and physical dependence.[47, 4]

  • Buspirone: Some studies suggest efficacy in persons with social phobia and less of a risk of physical dependence than is commonly seen with benzodiazepines. However, it has not been FDA-approved for the treatment of anxiety disorders in children.[47, 4]

  • Gabapentin: Recent studies suggest the efficacy of gabapentin for this indication; however, it is not FDA-approved for use in social phobia in adults or children.[50, 4]

  • Propranolol: Beta-blockers have been used to block the autonomic response in persons with social phobia. Preventing symptoms such as tremor and increased heart rate may lead to successful performance in social situations despite anxiety. However, propranolol should not be used in persons with asthma or in combination with other antihypertensive agents. This medication is not yet FDA-approved for use in children.[4]

  • Clonidine (alpha-adrenergic blocker) may work to block the autonomic response in persons with social phobia, similarly to the effect conferred by propranolol, and can be particularly useful in persons with comorbid posttraumatic stress disorder or acute stress reactions.[4]

  • Monoamine oxidase inhibitors (MAOIs): These agents are not approved for use in children, but they are FDA-approved for use in adults for unipolar depression. Phenelzine has been demonstrated to be effective in controlled studies. The dietary restrictions required when taking MAOIs reduces their popularity. Moclobemide, a newer reversible MAOI, has shown some efficacy in persons with social phobia. Selegiline (EmSam, a patch) may be superior to other agents in this class because of a slightly decreased risk of serotonin syndrome if used in the lowest dosage range.[4]

  • D-cycloserine: This medication has not yet been proven effective for the treatment of social phobia, but studies are ongoing.[51, 4]

Psychotherapy

Cognitive restructuring can be combined with in vivo exposure, performance feedback, and attention retraining and/or combined with nonspecific stress management or computer-based cognitive behavior therapy (CBT).[52]

Cognitive therapy has evidence-based efficacy.[53, 54]

A study of adults was a randomized controlled trial of 117 persons undergoing social anxiety disorder (SAD) treatment who received 16 individual sessions of either cognitive therapy (CT) or interpersonal therapy (IPT) and 1 booster session.

Twenty weeks after randomization, a posttreatment assessment was conducted using the Clinical Global Impression Improvement Scale, as assessed by independent, masked evaluators, and a secondary outcome measures was conducted independent of assessor ratings using the Liebowitz Social Anxiety Scale, the Hamilton Rating Scale for Depression, and patient self-ratings of SAD symptoms.

At the posttreatment assessment, response rates were 65.8% for CT, 42.1% for IPT, and 7.3% for WLC (Wait List Control). Regarding response rates and Liebowitz Social Anxiety Scale scores, CT performed significantly better than IPT, and both treatments were superior to WLC. At 1-year follow-up, the differences between CT and IPT were largely maintained, with significantly higher response rates in the CT versus the IPT group (68.4% vs 31.6%) and better outcomes on the Liebowitz Social Anxiety Scale.

CT and IPT led to considerable improvements that were maintained 1 year after treatment; CT was more efficacious than IPT in reducing social phobia symptoms.

Adolescents, particularly school-refusing adolescents, improve with the use of CT, especially when developmentally sensitive, and when this therapy is performed in an inpatient setting. This may be related to the improvement of automatic thoughts and cognitive errors with the use of CBT.[55, 56]

Behavioral psychotherapies, such as gradual desensitization, are effective in persons with social phobia. This technique involves gradually exposing the patient to simulated situations that normally cause anxiety in the patient. By mastering the situation without anxiety, the patient is eventually able to tolerate more situations that previously induced anxiety.[26]

Specific CBTs that have been found to be effective include computerized CBT (several types including "Coping Cat") and clinician-assisted computerized CBT (CaCCBT). Studies have shown that cognitive restructuring needs to include a component of in vivo exposure with attention retraining and performance feedback. As CBT interventions for social phobia tend not to generalize, it is important to design interventions specific to social phobia. Computer-based interventions have the advantage of eliminating scheduling problems, as they are convenient, potentially more sensitive to cross-cultural issues, appealing to children and adults, and more easily affordable.[25, 26, 28]

Cognitive and insight-oriented therapies have proved useful in treating social phobia. Individuals with social phobia often have significant cognitive distortions related to what other people could be thinking about them that might respond to restructuring.[26]

Stress management and relaxation techniques such as biofeedback, meditation, and deep breathing can lessen anxiety but are not sufficient alone in the treatment of social phobia.[47]

Group psychodynamic psychotherapy and individual psychoanalytic psychotherapy (an approach used for many years in the treatment of phobias) are approaches that are especially effective if combined with pharmacotherapy such as anxiolytics.[48, 57, 58]

A 2013 randomized control trial found that predictors of a less favorable treatment response include anticipatory worry, rumination, and harm-avoidant personality traits.[59]

A 2015 multisite study, The Genes for Treatment Study (GxT), sampled data from 1,519 children who received a course of CBT for anxiety at 1 of 11 sites: Sydney, Australia; Reading, UK; Aarhus, Denmar; Bergen, Norway; Bochum, Germany; Basel, Switzerland; Groningen, the Netherlands; Oxford, UK; Miami, Florda, USA; Cambridge, UK; and Amsterdam, the Netherlands. Data showed that social anxiety disorder, compared with other anxiety disorders, predicted poorer response and remission to CBT over and above comorbid mood disorders.[60]

Attention Bias Modification Training

Attention bias modification training (ABMT) is a promising alternative approach that may be effective in reducing anxiety in children and adolescents who do not improve with CBT. ABMT consists of a computer-based attention training program in which the person is trained to induce an attentional bias away from threat.[61]

ABMT has been shown to be more effective than placebo for reducing symptoms of anxiety in children and adolescents.[62]

Positive Cognitive Bias Modification for Interpretation

Cognitive bias modification of interpretations (CBM-I) training is an alternative method to reduce anxiety in children and adolescents who do not respond to either CBT or ABMT. CMB-I refers to computerized training to interpret ambiguity in a benign way so as to reduce threat-related interpretations and increase benign interpretations of ambiguous situations in participants' everyday lives. The goal of treatment for individuals with a prior interpretation bias includes training away negative social interpretation bias to reduce social anxiety symptoms. CMB-I has been proven to be more effective than placebo in laboratory studies for school-aged children.[63]

CMB-I has also been shown to be effective for adolescents.[64, 65]

Surgical Care

Surgical consultation for children with infantile facial hemangiomas could potentially prevent development of social anxiety disorder.[66]

Prevention

Toddlers and young children with excessive shyness and an inhibited temperament in childhood may be at greater risk of social phobia in adolescence. This may be in part related to the caregiver/parent’s response to the child’s emotional reaction to social situations, hence the importance of modeling and encouraging the young child’s ability to ignore negative internal cues and a gradual approach to coping with fears.[33, 34]

Because very low weight (600-1250 g) premature babies may also be at an even higher risk for later development of social anxiety disorder, caregivers/parents should be aware that typical parenting behaviors such as overprotectiveness may further increase risk for the development of social anxiety disorder.[10]

Surgical treatment of infantile facial hemangiomas (IH) may prevent the later development of social anxiety disorder. One study found that preteen children with involuted, untreated facial IHs had greater symptoms of social anxiety compared with children who received treatment for facial IH.[66]

Long-Term Monitoring

Social phobia often leads to extreme social isolation in children and can be accompanied by selective mutism and/or can be a precursor to depression. Intermittent explosive disorder (IED) can also co-occur with social phobia. Data from the National Comorbidity Survey Replication and Adolescent Supplement Study indicated lifetime presence of an anxiety disorder increased the rate of IED by almost 3-fold (7.8% in adolescents without anxiety compared with 22.9% in adolescents with anxiety).[14]  Thus, monitoring for severe anger outbursts may prevent significant morbidity.

 

Medication

Medication Summary

The goal of pharmacotherapy is to reduce morbidity.

Selective Serotonin Reuptake Inhibitors

Class Summary

This class of agents is emerging as the DOC for social phobia because of their clinical efficacy, ease of use, and excellent safety profile with relatively few adverse effects. Benzodiazepines are effective but require caution because of their lower safety margin and addiction potential. Benzodiazepines can be administered during the 4-6 weeks before SSRIs become effective. Buspirone is clinically efficacious, and studies indicate that gabapentin is also effective.

Escitalopram (Lexapro)

SSRI and S -enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic CNS activity due to inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may occur after 1-2 wk, which is sooner than conferred by other antidepressants.

Sertraline (Zoloft)

FDA approved for social phobia in adults and for OCD in children >12 y. Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane.

Fluoxetine (Prozac)

Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Available in susp.

Citalopram (Celexa)

Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Although SSRIs have not been compared with one another, based on metabolism and adverse effects, citalopram is considered SSRI of choice in patients with head injury.

SSRIs are antidepressants of choice because of their minimal anticholinergic effects compared with older typical antidepressants, which tend to be more likely to cause mania or behavioral activation. The specific choice of subtype of SSRI or SNRI depends to a large degree on adverse effects and drug interactions.

Fluvoxamine (Luvox)

Enhances serotonin activity because of selective reuptake inhibition at neuronal membrane.

Paroxetine (Paxil)

FDA approved for social phobia. Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Shorter half-life predisposes to SSRI withdrawal syndrome if abruptly discontinued; therefore, it is recommended to dose this medication twice a day.

Serotonin/norepinephrine reuptake inhibitors

Class Summary

These agents inhibit neuronal serotonin and norepinephrine reuptake.

Venlafaxine (Effexor, Effexor XR)

Indicated for social anxiety disorder, which is also known as social phobia. Patients have a 40-50% lifetime prevalence of coexisting major depressive disorder. Inhibits neuronal serotonin and norepinephrine reuptake. In addition, causes beta-receptor down-regulation.

Benzodiazepines

Class Summary

By binding to specific receptor sites, benzodiazepines appear to potentiate effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. It is best to avoid the use of these medications in children unless no other medications can be used. Benzodiazepine therapy in children younger than 10 years increases the risk of paradoxical excitation. Children older than 10 years old seem to be at higher risk than adults of drug-induced cognitive deficits, including decreased attention/concentration, slurred speech, and newly onset suicidal ideation and attempts, especially in the presence of comorbid depression.

Clonazepam (Klonopin)

May have quicker onset of action than SSRIs but has greater addiction potential and narrower therapeutic window.

Alprazolam (Xanax)

Extremely short half-life. Fastest onset of action and also may have most addiction potential.

Lorazepam (Ativan)

Sedative hypnotic with short onset of effects and relatively long half-life.

Diazepam (Valium)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.

Individualize dosage and increase cautiously to avoid adverse effects. Relatively long half-life.

Antianxiety agents

Class Summary

These agents reduce anxiety levels.

Buspirone (BuSpar)

A 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take as long as 2-3 wk for full efficacy. Low adverse effect profile. Efficacy not well established.

Anticonvulsants

Class Summary

Anticonvulsants are used if known to have anxiolytic properties.

Pregabalin (Lyrica) is not an FDA-approved treatment. It is an amino acid derivative of gamma-amino butyric acid, a GABA analogue, and is similar to gabapentin because it is an alpha-delta calcium-channel anticonvulsant that resembles benzodiazepines due to the ability to alter the balance between inhibitory and excitatory neuronal activity; however, it may have higher bioavailability and more rapid absorption, which may increase potency and thus may be more effective in decreasing social anxiety with panic disorder. A risk of dependence is possible.

Gabapentin (Neurontin)

Anticonvulsant with apparent anxiolytic properties.

Antibiotic, Miscellaneous

Class Summary

D-cycloserine is an emerging medication in the treatment of anxiety that may be effective but may cause adverse effects such as somnolence or cognitive slowing.

D-cycloserine (Seromycin)

A partial agonist at the glycine recognition site of the NMDA receptor in the amygdala. Inhibits cell-wall synthesis in susceptible strains of gram-positive and gram-negative bacteria and in Mycobacterium tuberculosis

Monoamine Inhibitor

Class Summary

These agents are usually reserved for patients who do not tolerate other types of antidepressants.

Phenelzine (Nardil)

MAOI most commonly used for anxiety disorders. Usually reserved for patients who do not tolerate or whose conditions do not respond to TCA or SSRI antidepressants.

Moclobemide (Moclamine)

Reversible inhibitor of monoamine oxidase type A. Because of selectivity and reversibility, dietary restrictions are not required while taking this medication; hypertensive crises are rare. Not available in the United States.

Selegiline transdermal (Eldepryl, Zelapar)

Irreversible MAOI. Has greater affinity for MAO-B than for MAO-A; however, at antidepressant doses, inhibits both isoenzymes. MAO-A and MAO-B catabolize neurotransmitter amines in CNS (eg, norepinephrine, dopamine, serotonin). Indicated for treating major depressive disorder. At lowest strength (ie, 6 mg delivered over 24 h), may be used without the dietary restrictions required for oral MAOIs used to treat depression.